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EC risk assessment important part of suicide prevention


April 26, 2010

EC risk assessment important part of suicide prevention

Patient suicides remain one of the top sentinel events reported to The Joint Commission, so safety officers should consider how EC issues might contribute to suicide risks.

The Centers for Medicare & Medicaid Services (CMS) could also have a say in your suicide prevention efforts should its inspectors visit your hospital.

The EC will likely be a focus in 2010 for surveyors when it comes to patient suicide risks, Sharon Chaput, RN, C, CSHA, director of regulatory and quality management at the Brattleboro (VT) Retreat, said during HCPro’s recent audio conference, “Suicide Risk Assessment: Comply with The Joint Commission’s National Patient Safety Goal and Keep Your Patients Safe.”

EC.02.01.01 sets the stage

At the very least, suicide hazards should be part of an annual EC risk assessment. EC.02.01.01, which requires hospitals to manage safety and security risks, is often cited by surveyors, sometimes for suicide-related concerns, Chaput said. Specifically, surveyors cite element of performance (EP) 1, which requires hospitals to identify safety and security risks associated with the EC through internal sources such as ongoing monitoring and root cause analysis, as well as credible external sources, including Joint Commission Sentinel Event Alerts.

Also, watch out for EP 3, which requires hospitals to take action to eliminate or minimize any identified safety and security risks in the physical environment. 

“There is no specific requirement from The Joint Commission at this time for how often to complete this risk assessment, but the key wording is ‘ongoing monitoring of the environment,’ ” said Chaput. “One easy way to accomplish this is to use an environment of care suicide risk assessment tool.” The tool can be used during hazard surveillance rounds.


Debate swirls about risk-free environs

There has also been a push from CMS in some Northeastern states to create a totally risk-free environment as a way to decrease inpatient suicides. It’s imperative to clearly articulate psychiatric standards of care at survey time, Chaput said. For example, parasuicidal behavior is a hot topic among CMS surveyors. 

“Surveyors often have no psychiatric background,” said Chaput. “They have a really hard time differentiating between a suicide attempt and self-mutilation.” 

If a CMS surveyor attempts to cite you for something like this, Chaput recommends informing the surveyor that it is not clinically therapeutic to create a clinically adverse environment. 

In other words, patients are going to be discharged into a world with pens and staplers, and ridding the hospital of these items will not facilitate the hospital in helping patients identify their feelings associated with hurting themselves and teaching them how to cope. It’s helpful to have some literature on hand to back up these points, said Chaput.


Joint Commission requirements for suicide prevention

The Joint Commission’s National Patient Safety Goals (NPSG) set a variety of mandates to better ensure the well-being of hospital patients.

NPSG.15.01.01 requires general hospitals treating patients for emotional or behavioral disorders and psychiatric hospitals to identify patients who are suicide risks.

Elements of performance under NPSG.15.01.01 include the following:

  • Performing risk assessments to identify patient or environmental characteristics that may increase or decrease suicide hazards
  • Addressing patients’ immediate safety needs
  • Providing suicide prevention information to at-risk patients and their families

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